The Challenge

Across all ages, diarrheal disease causes more illnesses than any other ailment and is second only to pneumonia as the largest killer of children under five years. Children who survive an episode of diarrhea, but experience recurring infections, are more likely to suffer from lifelong cognitive and physical impairments.

The state of the field is changing

Diarrheal disease is preventable and treatable. We can stop needless suffering—with knowledge and solutions available now. Support for research and development of new drugs and vaccines can accelerate an end to the crisis. Global progress is encouraging. Deaths have declined in recent years—but not fast enough. Children are still getting sick and surviving, yet facing the long-term consequences of repeated infections. To spur action and achieve sustainable impact, we must raise awareness of the threat, help improve understanding of the available solutions, and advance research on new tools and creative approaches.

The World Health Organization (WHO) defines diarrheaas the passage of three or more loose or liquid stools per day. Also known as gastroenteritis, diarrheal disease is caused by germs (both viral and bacterial) and parasites that are spread from the waste of an infected person to the mouth of another person through contaminated water, food, objects, or hands. During a diarrhea episode, fluids are depleted. Diarrhea becomes deadly when it results in dehydration that goes untreated. Infants and young children are especially vulnerable to rapid dehydration.

Shigella

Rotavirus

Adenovirus

Enterotoxigenic E. coli

Cryptosporidium

Campylobacter

It’s not a hopelessly long list of infections that we can’t do anything about.

- Dr. Eric Houpt, Professor of Infectious Diseases and International Health, University of Virginia Humanosphere

Who is at risk?

Diarrhea is a threat everywhere, but its frequency and impact are more severe in low-resource settings. Whether a child survives a diarrhea infection often depends on where he or she lives and receives treatment. In poorer countries, where access to hospitals or other forms of basic medical care—including intravenous (IV) fluids—may be limited, diarrheal disease can cause death or lasting impairments.

Diarrhea is deadly and dangerous

Deaths from diarrhea disproportionately impact children living in poverty due to:

Inadequate water supply/unsafe drinking water

Lack of access to sanitation (the safe disposal of human waste)

Limited access to soap and water and knowledge of good hygiene practices

Limited access to vaccines

Limited access to health care

Limited knowledge about diarrhea prevention and treatment

Globally, unsafe water and sanitation are the leading risk factors for diarrhea. Infants who are not exclusively breastfed or are malnourished, and immunocompromised young children and adults are also at great risk.

Despite substantial reductions in deaths among children under five years—from more than 1 million to roughly 500,000 each year in the last 15 years—diarrhea remains one of the deadliest threats young children face. It is responsible for about nine percent of all worldwide deaths in young children.

The latest available estimates on diarrheal disease-related deaths are summarized below. Findings across sources are relatively consistent.

From 2000 to 2015, diarrhea deaths among children under 5 years decreased by more than 50%.

Recent trends

Diarrhea deaths in children are on the decline. Progress has been faster in some regions and countries than in others. The IHME’s Global Burden of Disease (GBD) study found that, between 2006 and 2016:

The fastest reductions in diarrhea deaths in children under five years were in East Asia, Tropical Latin America, and Andean Latin America (greater than 66 percent reduction).

The largest absolute reductions in diarrhea death rates occurred in sub-Saharan African countries, where the mortality rate was reduced by more than 100 deaths per 100,000 in western sub-Saharan Africa (from 566 to 274 deaths per 100,000), eastern sub-Saharan Africa (from 271 to 116 deaths per 100,000), and central sub-Saharan Africa (from 347 to 146 deaths per 100,000).

Diarrhea deaths have decreased but incidence has decreased at a slower rate than diarrhea-related deaths. Infections are still a major problem. That means we need to get better at preventing–not just treating–diarrhea episodes through integrated public health approaches, including treatment, better availability of clean water and sanitation, and vaccination programs.

Most importantly, our progress proves that success is possible. Since 2006, worldwide diarrhea deaths in children under five years have declined even faster than the overall under-five death rate. That huge drop in deaths shows what can happen when we prioritize addressing diarrhea in children.

The top 10 countries where the most diarrhea deaths among children occur (measured in deaths per 100,000 people):

NIGERIA

97,854

Deaths

INDIA

66,157

Deaths

PAKISTAN

31,687

Deaths

DEMOCRATIC REPUBLIC OF CONGO

18,788

Deaths

ETHIOPIA

14,997

Deaths

NIGER

13,850

Deaths

CHAD

13,185

Deaths

MADAGASCAR

11,647

Deaths

MALI

11,386

Deaths

COTE D'IVOIRE

9,916

Deaths

There can also be significant inequities within countries, partially at the subnational level. Take Mozambique, for example. In adjacent regions, there are wide disparities in the burden of enterotoxigenic Escherichia coli (ETEC) and Shigella, with 36.4 deaths per 100,000 children in Cabo Delgado and only 7.4 deaths per 100,000 children in Niassa.

We can make public health gains when we invest in the right solutions and strategies—and then motivate policymakers to accelerate progress and ‘finish the job.’ Often, the biggest obstacle is people thinking that aid doesn’t pay off. With diarrhea, it has and still can.

Vaccines

WASH

Breastfeeding & Nutrition

ORS & Zinc

Research

Deaths are not the only problem—young children are still getting sick

Diarrhea infections are not declining as fast as the rate of deaths. While diarrhea deaths declined significantly among young children between 2000 and 2015, there were only 10 percent fewer cases of diarrhea, according to IHME’s GBD research. In 2016 alone, there were over a billion episodes of diarrhea in young children worldwide.

This means children are surviving, but not necessarily thriving—or not necessarily living their healthiest life. The magnitude is huge, but the problem still lacks the recognition and prioritization it urgently requires.

Diarrhea has devastating, lasting implications for children and families

Many studies demonstrate that repeated diarrhea infections, especially within the first two years of life, can cause long-term disability, diminishing a child’s quality of life and potentially causing premature death.

Recurring enteric infections, such as those caused by diarrheal disease, may lead to intestinal inflammation and damage in the gut. Compromised gut health inhibits nutrient absorption in the body. This can lead to malnutrition and lasting health consequences, such as stunted physical growth, impaired cognitive development, and/or increased susceptibility to infections, including diarrheal disease and pneumonia. The better we understand these implications, the better we can make meaningful policy decisions to break the cycle of poor health by using strategies and solutions that work together.

We are saving more lives from diarrhea, but what is the future for kids who grow up sick much of their lives? Once a child developmentally misses an opportunity to grow, you can never fix that.

No child’s life should be limited by diarrhea

When a young child has multiple episodes of diarrhea, he/she is left vulnerable to other infections, malnutrition, and stunting, which can take a lifelong toll on that child’s ability to grow, thrive, and contribute to society.

When a child gets sick, he/she may miss school and his/her parents must pay for care, which could amount to a significant portion of that family’s income.

They may also need to stay home to care for their child or take him/her to the clinic or hospital, losing wages from missed time at work.

Especially in lower-income countries, the cost of diarrhea can push entire families into poverty, known as “medical impoverishment.”

Often, when one child gets sick, so do other family members. The impact is bigger than one child.

Many families are forced to make the impossible choice

When a children falls ill with diarrheal disease, families often have to chose between treatment and family finances. Treatment costs can cause significant financial strain on households and health care systems alike. In Malawi, where 72.2 percent of the population lives on less than US$1.25 per person per day, the mean household costs for patients seen in rural health centers were US$19.16 and US$1.81, respectively, for inpatient and outpatient treatment. Patients seen at urban hospitals had mean household costs of US$25.36 and US$15.48, respectively, for inpatient and outpatient treatment.

Yes, we've made progress, but there's more to be done.

It’ll take focus and prioritization from governments and donors, integrated efforts such as the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD), and continued pressure and calls for accountability by advocates.